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Geriatrics > Diabetes Management > Flashcards

Diabetes Management Flashcards

1
Q

Diabetes management in older adults requires an individualized approach that considers…

A

Duration of diabetes + presence of complications
Co-morbid health conditions + medications
Functional status, cognition
Availability of supports

Kidney fx decline
Brain more sensitive to hypoglycemia
Altered senses - decreased vision, hearing, peripheral neuropathy

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2
Q

Cognitive impairment and diabetes are interlinked via…

A

Cognitive decline (via medications, or aging) may lead to reduced ability to perform diabetes management +/- self care tasks. May lead to hypo or hyperglycemia which can further induce cognitive decline.

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3
Q

The ACCORD trial explored blood glucose targets in older adults. This trial found that…

A

Harms are evident with aggressive BG lowering and were associated with increased mortality - targets and treatments need to be individualized to optimize risk vs. benefit

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4
Q

Intensive lowering of A1C is associated with ____. However…

A

Decreased rates of nephropathy, neuropathy, retinopathy, and CV events. However, time to benefit is usually 5-10+ years of treatment.

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5
Q

Achieving a “balanced” A1C (7.5-8.5%) is associated with…

A

Minimal hypoglycemia
Decreased medication AE’s and regimen complexity

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6
Q

A shift in diabetes treatment is…

A

Using medications that have evidence for improving clinical outcomes

Metformin, GLP-1 RA’s, SGLT2-inhibitors

Insulin + sulfonyl-ureas still most-used antihyperglycemics…

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7
Q

When setting glycemic targets for older patients, we need to consider…

A

Duration of diabetes
Risk of CV events vs. risk of hypoglycemia
Functional capacity, other cormorbidities
Available resources + supports

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8
Q

A healthy older adult with diabetes is considered…

A

Functionally independent
Few comorbidities, no cognitive concerns
10+ years of healthy life expectancy

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9
Q

A healthy older adult with diabetes can have these glycemic targets for treatment…

A

Same BG as someone in younger population
A1C below 7%
Pre-prandial 4-7 mmol/L, post-prandial 5-10 mmol/L

Will likely have a positive benefit

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10
Q

A functionally dependent adult can be classified as someone who has issues with ____. Good glycemic targets for them would be…

A

IADL’s.
A1C 7.1-8%.
Pre-prandial 5-8 mmol/L, post-prandial <12 mmol/L

Avoid insulin, sulfonylureas !

Higher risk of hypoglycemia, and may not be as likely to benefit in ~10 years

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11
Q

People who are classified as severely frail and/or have dementia usually have looser BG targets; this is usually around…

A

A1C 7.1-8.5%
Pre-prandial 6-9 mmol/L, post-prandial <14 mmol/L

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12
Q

Glycemic targets for an individual in end-of-life care…

A

Are irrelevant - provide comfort care and avoid symptomatic hypo/hyperglycemia

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13
Q

Trends in diabetes management in long-term care include…

A

Overtreatment - high rates of insulin/sulfonylurea use, high rates of hypoglycemia - knowledge gaps in staff regarding diabetes care.

Main goal is to avoid hypoglycemia

Not really any point in “diabetic diets,” quality of life is more important

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14
Q

Hypoglycemia is defined by…

A

BG < 4 mmol/L

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15
Q

Hypoglycemia can result in severe consequences in older adults such as…

A

Falls, injuries
Confusion, delirium - repeated episodes increases risk of dementia
Seizures, comas
CV event risk

Overall increased risk of mortality

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16
Q

Risk factors for hypoglycemia include…

A

More intensive BG control
Previous episodes
Hypoglycemia unawareness - autonomic neuropathy
Cognitive impairment or issues with mobility

Unpredictable eating patterns

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17
Q

Medications that increase risk of hypoglycemia include…

A

Diabetes medications - Basal-bolus insulin > intermediate acting insulin > long-acting basal insulin - sulfonylureas > repaglinide

Others - beta-blockers, quinolones, alcohol

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18
Q

Autonomic signs + symptoms of hypoglycemia include…

A

Shaking, palpitations, dry mouth
Anxiety, sweating (night sweats)
Hunger, nausea, paleness

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19
Q

Neuroglycopenic signs + symptoms of hypoglycemia include…

A

Difficulty concentrating, speaking
Confusion, irritability
Weakness, decreased coordination, falls
Vision changes, headache

20
Q

Asymptomatic hypoglycemia is associated with…

Population?

A

Increased age
Longer duration of diabetes
Repeated episodes of hypoglycemia, intensive BG control
Cognitive impairment

21
Q

Important patient/caregiver education that is key for addressing hypoglycemia risk includes…

A

Skipping prandial insulin/repaglinide dose if missing a meal - but also importance of eating regularly
Ensure a hypoglycemia management plan is in place

22
Q

We can help address hypoglycemia risk via reviewing…

A

Glycemic targets
Adherence to medications - double dosing?
Reeassessment of medications that may contribute to hypoglycemia

Symptomatic trends

23
Q

Hypoglycemic episodes can be managed via…

Treatment

A

15-20g carbohydrates
Glucagon for severe episodes (lack of consciousness)

24
Q

Continuous glucose monitoring is recommended for older adults with…

A

Type 1 diabetes
Type 2 diabetes on basal-bolus insulin regimens (asymptomatic or recurrent hypoglycemia)

25
Q

For cardiovascular risk management in diabetes, these medications are recommended…

A

Statins for all patients 40+
ACEI/ARBs for all patients 55+

Remember to consider co-morbidities, frailty, AE risk vs. benefit (time to benefit)

26
Q

General considerations to take when evaluating a diabetes medication regimen include…

A

Medications with low risk of hypoglycemia are preferred - avoid overtreatment
Consider comorbidities (heart failure, CVD, CKD) - cardio/renal benefit from medications?

Re-evaluate treatment goals + regimens as health, functional status, or social supports change

Consider that deprescribing will increase A1C by amount it is lowered.

27
Q

Lifestyle/non-pharm measures that are always good to consider with diabetes management in older adults include…

A

Nutritional education
Weight loss (but NOT in frail, older adults)
Exercise - resistance training

28
Q

Pros of using metformin include…

A

Effective 1st line agent in reducing A1C and providing CV benefit
Low hypoglycemic risk

Affordable, convenient

29
Q

Cons of using metformin include…

A

Renal elimination - risk of accumulation in CKD. Not recommended if GFR < 30 mL/min
GI upset, diarrhea
SADMANs drug
Monitor for vitamin B12 deficiency periodically

30
Q

Pros of using SGLT2 inhibitors include…

A

CV + Renal outcome benefits
Low risk of hypoglycemia - less effective for A1C lowering, especially with reduced renal function

31
Q

Cons of using SGLT2 inhibitors include…

A

Risk of orthostatic hypotension - volume depletion
Yeast infections, UTI’s, worsening urinary incontinence

$$$

32
Q

Pros of using GLP-1RA’s include…

A

CV + Renal benefit
Effective A1C lowering, but still low risk of hypoglycemia
Weight loss if desirable

Once weekly injectable available

33
Q

Cons of using GLP-1RA’s include…

A

N/V/D, decreased appetite - may increase frailty
Requires injection

$$$

34
Q

Pros of using DPP-4 inhibitors include…

A

Low hypoglycemia risk - moderate effect on A1C
Well-tolerated + convenient, no effect on weight

35
Q

Cons of using DPP-4 inhibitors include…

A

No established benefits for CVD, CKD
May need to avoid in heart failure

$$$

36
Q

Pros of using sulfonylureas include…

A

Effective A1C lowering (~1%)

Affordable, convenient

37
Q

Administration of insulin in older adults requires…

A

Adequate cognitive, visual, and motor skills

38
Q

Cons of using sulfonylureas include…

A

Hypoglycemic risk especially with irregular eating habits
Weight gain
No eastablished outcomes - potentially may increase CV risk

39
Q

This insulin regimen is associated with the lowest-risk of hypoglycemia…

A

Once daily basal insulin - long acting insulin analogues

40
Q

This insulin is associated with the highest risk of hypoglycemia…

A

Multiple daily insulin injections - basal + bolus

May need re-evaluation in older adults with cognitive decline, limited function, or life-limiting illness

41
Q

When adjusting insulin dosing, we should…

A

Fix lows first, fix highs later
Adjust by 1-2 units at a time, and 1 insulin at a time

42
Q

____ BG levels are best for checking lows…

A

Pre-prandial

43
Q

____ BG levels are best for assessing adequacy of bolus insulin…

A

Post-prandial

44
Q

Frequency of BG monitoring…

A

Needs to be individualized - overmonitoring is common

Consider stability of treatment regimen + risk of hypoglycemia

Is it actionable by either patient or HCP??

45
Q

A1C should be monitored…

A

Every 3-6 months

46
Q

In older adults, we need to be more aware of ____ with diabetes medications

Circumstance?

A

Sick-day management

SADMANS

Geriatrics (12 decks)

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